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| Lead Agency |
Goldman Institute on Aging, University of California, San Francisco |
| Title |
Northern California Chronic Care Network for Dementia Demonstration Project |
Grant Amount
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$993,133 over three years |
| Project Partners |
Kaiser Permanente San Francisco; Brown & Toland Medical Group; Sutter Health-Central Area; Alzheimer's Association of Greater San Francisco/Bay Area; Alzheimer's Association of Greater Sacramento Area |
| Sample |
710 total: 363 patients and 346 caregivers |
| Background |
This project was part of a national effort, the Chronic Care Network for Alzheimer’s Disease (CCN/AD), sponsored by the National Chronic Care Consortium and the Alzheimer’s Association. It was designed to test new models of integrating primary, acute, and long-term care services for people with dementia under managed care. The CCN/AD model includes treatment protocols and instruments developed under the national initiative. Components include: identification of people with possible dementia; diagnostic assessment; a blueprint for ongoing medical and nonmedical care management; and programs and materials for caregiver information support. Project aims included earlier and more consistent identification and diagnosis of AD and dementia, better medical and nonmedical care management, and more timely connections of patients and families to community agencies, which provide supportive services. |
| Research Questions |
Would the CCN/AD model effect patient and family caregiver
satisfaction, or result in changes in service utilization
pre- and post-project enrollment?
What factors are associated with providers’ use of and attitudes
about project tools at follow-up? |
| Intervention |
Components of the CCN/AD model were implement in
three health care systems: Kaiser Permanente, San Francisco
(KP); California Pacific Medical Center/Brown and
Toland (CPMC/BT); Sutter Health Center.
Assessments included:
– Initial patient/caregiver characteristics
– Provider site visits (structural characteristics/staff perceptions)
– Patient and caregiver telephone satisfaction survey
– Provider Survey (tool use and provider attitudes)
– Service Utilization (6 months pre- to 12 months post) |
| Results and Findings |
Patient Satisfaction: Discussions with patients regarding
coordinating care from family and friends and related issues
of informal social support appear to be of singular importance
to patient satisfaction.
Caregiver Satisfaction: Discussions about treatment options
are strongly related to caregiver satisfaction with physician
care.
Pre/Post Service Utilization: Among participants who were
enrolled in KP, emergency room, primary and specialty care
visits declined significantly in first and second 6 month periods
after project enrollment. |
| Lessons Learned and Implications |
Enrollment in the project and AD chapter care consultations
and referrals may have played a role in reduced primary
care, specialty and ER specialty visits for Kaiser
patients.
Assessments included:
– Initial patient/caregiver characteristics
– Provider site visits (structural characteristics/staff perceptions)
– Patient and caregiver telephone satisfaction survey
– Provider Survey (tool use and provider attitudes)
– Service Utilization (6 months pre- to 12 months post) |
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| Lead Agency |
Jewish Family & Children's Services of San Francisco |
| Title |
Expansion and Evaluation of the "Identification and Early Intervention" Program |
Grant Amount
|
$740,000 over three years |
| Project Partners: |
Brown and Toland Physician Services Organization; University of California, San Francisco (UCSF) Division of Geriatrics, Mt. Zion Hospital |
| City/Region |
San Francisco |
| Project Description: |
This project builds upon a pilot project begun in 1993, in which physicians and their staffs identify elderly patients who appear to be in decline and in need of supportive services, and refers them to Jewish Family and Children's Services (JFCS). JFCS sends a social worker to conduct an in-home assessment of the patient's overall living situation and needs, and makes arrangements for necessary services. The project also trains members of physicians' office staff as Geriatric Resource Persons (GRPs). Initial pilot project data indicate that the costs of these interventions (the social work assessment and in-home supportive services) were more than offset by a reduction in those patients' hospital, emergency room, and nursing home costs. In this expansion and evaluation, Brown and Toland refine and expand the model throughout its physician groups, and conduct a comprehensive evaluation of its impact on costs, patient and physician satisfaction, and the process of care. The project also enhances the Geriatric Resource Person Training Program by converting it into a 10 hour, three-week course at a university, resulting in receipt of a continuing education certificate. Brown and Toland have increased the number of physician groups participating in the demonstration, which include primary care physicians at the University of California, San Francisco (UCSF) and Mt. Zion Medical Center. The UCSF Division of Geriatrics evaluation is of the project's impact on costs, patient and physician satisfaction, and the process of care. |
| Contact: |
Amy Rassen
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| Lead Agency |
Kaiser Permanente Tri-Central Continuing Care Department |
| Title |
Implementation and Evaluation of the Community Partners Project |
Grant Amount
|
$990,000 over 3 years |
| Project Partners: |
Visiting Nurse Association Foundation, City of Los Angeles Department of Aging, County of Los Angeles Area Agency on Aging |
| City/Region |
Los Angeles |
| Project Description: |
This project tests the addition of a home and community-based services benefit (up to $2,000 per member, over a three-month period) for elders enrolled in the Kaiser Permanente Tri-Central's Medicare managed care program. The program implements a new geriatric screening questionnaire mailed to all enrolled elders in order to identify frail elders and those most at risk for adverse events, e.g., falls, hospitalizations, and nursing home placements. Those identified elders are referred to a geriatric social worker at Kaiser who assesses their needs and arranges for needed home and community-based services, such as transportation, homemaker/chore services, personal care, nutritional counseling, and home modification. The evaluation assesses whether receiving such services prevents a patient from suffering a decline in their ability to function, promotes optimal health status and quality of life, and minimizes the use of more expensive medical care services. It also determines which subset of frail elders most benefits from the services, and which specific services have the greatest impact. Finally, elders and their families are often initially reluctant to pay for these services, even when they can afford them. The project tests the assumption that if an elderly person receives three months of needed services as a Kaiser benefit, he/she will recognize the value of the services and be willing to pick up the ongoing costs. |
| Contact: |
Nancy Gibbs |
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